Guidance for the prevention and

control of outbreaks of Norovirus in

hotels and restaurants

North Yorkshire and York District Control of Infection Committee

FINAL VERSION
September 2017
Acknowledgement:

This guidance is based on “The Control of Viral Illness in Hotels and Other
Accommodation Providers”, North Devon District Council, 2004 and the leaflet
“Handling of Live Oysters at Retail”, Colchester Borough Council, 2010

Replaces version: Guidance for the prevention and control of outbreaks of

Norovirus in hotels and restaurants, District Control of Infection Committee
(North Yorkshire and York), FINAL VERSION June 2011

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Contents
Page
Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
What causes norovirus illness? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
What are the symptoms of norovirus? . . . . . . . . . . . . . . . . . . . . . . . 5
How does norovirus spread? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
The prevention and control of norovirus outbreaks. . . . . . . . . . . . . . . . 6
Action needed before an outbreak. . . . . . . . . . . . . . . . . . . . . . . . . . 6
Action needed when an outbreak occurs. . . . . . . . . . . . . . . . . . . . . . . 8
How do I know if I’ve got an outbreak? . . . . . . . . . . . . . . . . . . . . . . 8
Dealing with illness in guests or residents. . . . . . . . . . . . . . . . . . . . . . . 11
Dealing with staff illness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Cleaning and disinfection procedures. . . . . . . . . . . . . . . . . . . . . . . . . . 14
Precautions to take for guests on departure / before arrival. . . . . . . . . 22
Appendices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Appendix 1: Flow chart showing action plan for premises 25
before an outbreak of viral gastroenteritis occurs. . . . . . . . . . . . . . .
Appendix 2: Contacts list for Environmental Health in North 26
Yorkshire and York. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Appendix 3: Flow chart showing action plan where an 27
outbreak of gastroenteritis occurs . . . . . . . . . . . . . . . . . . . . . . . . . .
Appendix 4: Collection of faecal specimens. . . . . . . . . . . . . . . . . . . 28
Appendix 5: Faecal specimen request form. . . . . . . . . . . . . . . . . . . 29
Appendix 6: Specific note on oysters. . . . . . . . . . . . . . . . . . . . . . . . 31
Appendix 7: Information for hotel guests. . . . . . . . . . . . . . . . . . . . . 33
Appendix 8: General information for the public. . . . . . . . . . . . . . . . 34
Appendix 9: Illness report forms. . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Appendix 10: Outbreak summary sheets. . . . . . . . . . . . . . . . . . . . . 42

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Background

Outbreaks of viral gastroenteritis are commonly caused by Norovirus and

sometimes referred to as ‘winter vomiting disease’. This illness is particularly
common in situations where large numbers of people live in close proximity
e.g. hotels, restaurants, hospitals, residential care homes and nursing homes.
An outbreak of Norovirus can cause significant disruption to the running of a
hotel or restaurant as the infection can be easily spread if there is not a co-
ordinated action plan to ensure the highest of hygienic standards are in place.
Whilst there may be a limited amount you can do to prevent a single case of
norovirus infection starting at your premises, it is possible through prompt
action to control and minimise the spread and consequences of an outbreak.
This guidance has been developed in the absence of nationally agreed
guidance and tries to supply as much detail as is possible. The list of advice is
unlikely to be exhaustive. It is hoped that the information given will assist in
controlling and preventing the spread of any cases of viral gastrointestinal
illnesses that may occur.

What causes Norovirus illness?

Norovirus particles are microscopic and cannot be seen or tasted in foods.

Unlike food poisoning bacteria they do not grow on food but can survive in
foods and use the food as a vehicle to gain access to living tissue. Norovirus
is a purely human pathogen and infected individuals will excrete the virus in
their stools and vomit. Affected persons will continue to excrete viruses for
several days after symptoms have ceased and in some cases for up to 2-3
weeks. Norovirus is resistant to some cleaning chemicals and may survive
within the environment for several days. Norovirus and other viruses causing
gastroenteritis can be found in the following sources.

 Human cases - they may be a guest, member of staff or a visitor. They

may be unaware they are infected, only becoming ill once they are in
the hotel.
 Live foods such as contaminated shellfish e.g. mussels, clams, oysters.
All shellfish should be purchased from reputable suppliers and be
correctly handled. It should be thoroughly cooked wherever possible
(see also appendix 6).
 Sewage contaminated water has been implicated in outbreaks. Salad
foods irrigated with wastewater are a potential source of infection.
*Outbreaks amongst guests can often follow an outbreak amongst staff*

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What are the symptoms of Norovirus?

The most common symptoms are nausea, vomiting and diarrhoea. Symptoms
often start with the sudden onset of nausea followed by projectile vomiting
and watery diarrhoea. However, not all of those infected will experience all of
the symptoms. Some people may also have a raised temperature, headaches
and aching limbs. Symptoms usually begin around 12 to 48 hours after
becoming infected. The illness is self-limiting and the symptoms will last for 12
to 60 hours. Most people make a full recovery within 1-2 days, however some
people (usually the very young or elderly) may become very dehydrated and
require hospital treatment.

How does Norovirus spread?

The virus is found in the vomit and faeces of an infected person and is easily
transmitted from one person to another. A single vomit can spray tiny particles
through the air. Although these will not be generally visible they can travel
quite far within a room before settling to contaminate surfaces and objects
some distance from the individual.

It can therefore be spread by:

 Direct contact with an infected person (especially when caring for

someone who is ill or sharing foods or utensils);
 Consuming contaminated food or water including e.g. shared boxes of
biscuits, chocolates and fruit.
 Contact with contaminated surfaces or objects. Touching a
contaminated surface and then placing the hand in the mouth can
cause infection.
 Poor hand washing after using the toilet leaves hands contaminated
with the virus. Hands will then contaminate any surface they come in
contact with. Toilets and bathrooms become a major risk area for
environmental contamination.
 Equally food is very easily contaminated by direct contact with an ill
person, or being prepared on contaminated surfaces.
Billions of Norovirus particles are shed by an infected person but swallowing
as few as 10 - 100 virus particles may be enough to cause illness.

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The prevention and control of Norovirus outbreaks

Don’t wait for several cases of sickness and diarrhoea to occur before you put
controls in place to prevent the spread of an outbreak.

Action needed before an outbreak

Develop an action plan. Be prepared! If an outbreak occurs swift and

effective action is essential to prevent more people becoming exposed to
Norovirus and to prevent an outbreak increasing in size. This is best achieved
with some forward planning. A flow chart summary is available in Appendix 1.

1) Create an Outbreak Control Group

This will consist of key personnel including Senior Management, Heads of

Department, cleaning supervisors, etc. The aim is to develop an “Action Plan”.
Designate one person to be in overall charge of co-ordinating the outbreak. It
is more likely to be effective when staff can turn to one person for advice.

2) Develop an “Action Plan”

Develop procedures and strategies to deal with an outbreak. This is the

preparation you will need to ensure you can handle an outbreak quickly.

3) Train staff

Train staff in the procedures for dealing with an outbreak. All staff (including
cleaners, chambermaids, night staff, waiting staff, coach drivers, etc) should
be trained to immediately notify management of any instances of sickness or
diarrhoea in private rooms and public areas, or about general comments
made by residents or guests about feeling ill. In this way you are likely to be
aware of suspected cases at the earliest opportunity.

4) Create a Cleaning Hit Squad

Put together a Hit Squad of cleaning staff who are ready to go into action at
the first signs of an outbreak. This will help prevent confusion and panic if an
outbreak does occur. The Hit Squad must not include any food handlers.

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5) Ensure Adequate Chemical Supplies

Ensure you have a stock of chemicals on site that can be used to clean up
incidents of vomiting and diarrhoea. Ensure that you are aware of the
necessary dilutions required to ensure a 0.1% hypochlorite solution
(1000ppm) can be achieved.

6) Laundry Facilities

Ensure your laundry facilities are capable of achieving hot water temperatures
in excess of 60ºC. Where practicable, provide soluble alginate linen bags.
These can be placed directly into washing machines and open up at warm
water temperatures. This minimises the risk of further handling of soiled
laundry.

7) Contract Cleaner

Identify a contract cleaner who will be able to provide cleaning staff at short
notice, to provide cover in case of significant staff illness.

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Action needed when an outbreak occurs

How do I know if I’ve got an outbreak?

If you have two or more cases of illness of diarrhoea or vomiting reported to

the hotel or restaurant in the same week occurring in either guests or staff
then the premises should inform Environmental Health at the local authority.

If, following discussion with the Environmental Health Officer it appears that
the numbers of cases increase the following day or during the week such that:

1. there are a large number of people with diarrhoea and vomiting

reporting illness to the hotel or restaurant (or directly to PHE Y&H or
EH)
2. over half have vomiting
3. the onset of illness is sudden and occurs a short time after the visit or
during the stay (average incubation period is 24 to 48 hours)
4. recovery of illness is quick (average duration 12 to 60 hours)
5. no one with illness has submitted a faecal sample that has grown a
different organism in the laboratory
then it is likely that there is an outbreak of viral gastroenteritis linked to the
premises. The EHO should then discuss the outbreak with PHE Y&H.

Clearly, with a large hotel, you may expect a certain number of cases of
vomiting or diarrhoea each week depending on the characteristics of the client
group. However, when it becomes apparent that the number of cases
exceeds the norm then this should trigger your Action Plan.

1) Contact Environmental Health at your Local Authority (see Appendix

2 for contacts list)

Do not assume that an outbreak of vomiting and diarrhoea is viral in origin; it

might be caused by bacteria e.g. Salmonella, E. coli or Campylobacter.

Contact your Environmental Health Officer as soon as possible in order for an

initial investigation to be made. EHOs will try to give an indication of the likely
cause of illness as being either bacterial or viral in origin. Confirmation can
take a few days as samples of food or faeces will need to be analysed in a
laboratory. Where it is evident that the likely source of the outbreak is
Norovirus, then the following action should be taken. A Flow Chart summary

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is available in Appendix 3 showing the roles for the premises as well as
EHO’s and HPU.

2) Assemble the Outbreak Control Group

Call the Outbreak Control Group together to go over your Action Plan
including the responsibilities and duties of key personnel. This includes the
verification of cleaning and disinfection procedures and protocols to ensure
good personal hygiene amongst both guests and staff.

3) Activate the Cleaning Hit Squad

Incidents of sickness may occur at any time of the day and so the ‘Hit Squad’
of trained cleaning staff should be available at very short notice 24 hours a
day. This should continue until the outbreak has ceased and until at least 48
hours have passed without any further incidents arising.

Consider the introduction of a shift rota during the period of an outbreak and
ensure thorough training is given to all night staff that may be called upon to
clean affected areas.

4) Collect Information & Faecal Specimens

The EHO will leave a number of faecal specimen postal kits including pots,
labels, forms and postal packaging for you to distribute to affected guests and
staff (see appendix 4 and 5). They will also require you to complete an
Outbreak Summary Sheet giving details of all the guests/staff who have been
ill. Examples are given in appendix 9 and 10

5) Determine the Severity of the Outbreak

Proprietors of hotels and restaurants should consider whether closing part or

the whole of the premises, or phasing/suspending the arrival of new guests is
appropriate to enable a full programme of environmental cleaning and
disinfection to take place. In theory, a 48-72 hour closure may be adequate,
provided no more guests and staff are ill and a cleaning and disinfecting
programme is undertaken as described.

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Should I Inform Tour Operators and Guests who have not yet arrived?

Where an outbreak occurs PHE Y&H or the Environmental Health Officer may
advise that tour operators and pre-booked guests should be informed of the
situation. It is important that prospective guests are given sufficient
information to make an informed choice and are able to avoid the possibility of
exposure to illness if they wish to do so (see Appendix 3).

What is the Legal Position?

Whilst it is not always possible to prevent an initial infection being brought into
a hotel it is possible to take reasonable precautions and show due diligence to
avoid the risk of harm to customers. Failure to take immediate and effective
action may result in a reasonable claim. The fact that a number of guests
were ill as a result of a known outbreak is all the proof that is generally
needed for a “class action” and compensation may be received for pain and
suffering, and for loss of money with regard to expenditure and income. It is
likely that the damage will be greater if the manager was aware of the
problem and did nothing to resolve it. Often guests feel most aggrieved if they
feel they have not been adequately informed and this can be avoided through
early action.

N.B. This is not a definitive legal opinion and the Courts remain the final
arbiter of legislation

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Dealing with illness in guests or residents

1) Illness Report Form

Complete an Illness Report Form for each affected person. An example is

found in Appendix 9. One form should be FULLY completed for each ill
person. This will help you see if there are any common links between
sufferers.

2) Obtain a Faecal Specimen

It is not necessary for each ill person to submit a faecal specimen for testing
in order to confirm an outbreak but specimens from at least six different
individuals are requested for this purpose (Appendix 4). Specimen pots are
available from the EHO or by ill staff or guests seeking medical attention
directly. The earlier that specimens can be submitted for analysis, the greater
the chances of identification of the virus, and therefore being able to advise
residents or guests positively. EHOs may collect sample pots in the initial
days of the outbreak in order to speed up the detection process but this may
also be done by provision of postal kits. Ensure the label on each pot is fully
completed and a Faecal Specimen Request Form accompanies each
specimen as without these it is unlikely specimens will be analysed. An
example of a completed label and a blank form is provided as Appendix 5.

3) Stress Good Personal Hygiene

Instruct guests, staff and other visitors in the importance of good personal
hygiene especially hand-washing. This is particularly important before eating.
In severe cases, it may be appropriate to provide hand wash facilities prior to
the entrance to the restaurant. It would be advisable to cease self-service
buffets

4) Isolate Affected Persons

For hotel guests, actively encourage affected people to stay in their rooms
and avoid all public areas. Food and drink should be taken up to rooms rather
than affected persons attending communal dining areas. Visitors to the
premises e.g. contract workers, or friends and relatives visiting ill people
should be discouraged.

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5) Provide Information to Guests

Information should be provided to guests and to new arrivals. You should

notify them of the symptoms of the illness and the procedures in place to
prevent a spread of infection. Quick reporting of illness is vital to ensure that a
clean up can be done as soon as possible. An example leaflet is given in
Appendix 7 and 8 which could also be posted up in public areas. The use of
leaflets and posters should only be used as part of a process of face to face
informing of guests.

A hand washing poster is also available to download from

http://www.who.int/gpsc/clean_hands_protection/en/ and is shown in appendix
8

6) Provide Extra Facilities for Ill Hotel Guests

This should include drinking water, towels and a bucket, sick bag or other
receptacle in case of sickness.

7) Do Not Send Symptomatic Guests or Staff to the GP

It is advisable to ring the GP rather than directing guests to go straight to the

surgery. This will reduce the risk of spread of infection, and the GP may
choose to visit depending on circumstances. This will reduce the risk of
spread of infection. Alternatively, contact NHS 111 for information and advice.

8) Give Prior Warning if Hospital Attendance is Required

If an affected person requires hospital treatment you must give prior

notification as this will allow the hospital to make arrangements on arrival to
ensure that the risk of further infection is minimised.

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Dealing with staff illness

In the event of a member of staff reporting that they have vomiting, diarrhoea,
abdominal pains or nausea, they must immediately be sent home. Unwell
individuals are likely to be most infectious at the onset of the illness.

 An Illness Report Form should be completed. (Appendix 9)

 Faecal specimens should be obtained from any infected staff.
(Appendices 4 and 5)
 Staff should refrain from work until at least 48 hours after the last
episode of diarrhoea or vomit. In exceptional circumstances or where
standard interventions are not successful in controlling the outbreak
advice may be given by PHE Y&H or EHOs to extend the exclusion
period.
 An outbreak summary sheet should also be completed for staff for the
premises to share and discuss with EHOs/PHE Y&H.
Staff who live on the premises or share communal facilities should be
transferred, wherever possible, to single accommodation with en-suite
facilities. Where such accommodation does not exist then regular (ideally
hourly) cleaning of affected areas should be arranged.

Ensure staff areas including bathrooms, toilets and communal areas are
included in the cleaning and disinfection programme. If a member of staff is
sick within the kitchen or food preparation areas then the potential for illness
to spread will increase significantly. All foods in the area which may have
become contaminated must not be used for human consumption and must be
promptly disposed of in a safe manner.

The same detailed cleaning programme (see “Cleaning and Disinfection

Procedures”) will need to be introduced within the kitchen and food areas with
frequent changing of cleaning cloths and paper towels. It must be assumed
that all surfaces may be contaminated. Consideration may need to be given to
the use of an outside caterer in this situation. Thorough cleaning and a 72
hour period prior to the reuse of the kitchen should be ensured.

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Cleaning and disinfection procedures

Cleaning and disinfection is the single most important factor in preventing the
spread of the virus and if carried out effectively it should reduce the risk of
further spread of infection.

1) Ensure the Hit Squad is Readily Available

Ensure the “Hit Squad” of trained cleaning staff is on hand at very short notice
24 hours a day. This should continue until the outbreak has ceased until at
least 48 hours have passed without any further incidents arising.

2) Cleaning Facilities

A cleaning sink with hot and cold water should be designated for the exclusive
use of Hit Squad cleaning staff. It must NOT be within any food preparation
area.

3) Changing/Washing Facilities

Designate specific changing and washing facilities for Hit Squad cleaning
staff, including hot and cold water, liquid soap, and paper towels.

4) Cleaning Equipment and Supplies

Ensure your supplies of cleaning equipment and cleaning chemicals are

adequate. Where necessary, ensure that it is thoroughly cleaned, disinfected
and stored in a dry condition.

Equipment needed can include:

 Hypochlorite-based disinfectant solution;
 Disposable paper towels;
 Plastic scrapers/ Dust pans;
 Detergent;
 Disposable cloths;
 Disposable mop heads;
 Soluble alginate laundry bags;
 Buckets;

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  Bag tags;
 Plastic bags (in a distinctive colour);
 Disinfectant wipes;
 Sick bags;
 Absorbent granules;
 Disposable foot covers;
 Hazard warning tape;
 Air freshener.

5) Protective Equipment

Provide protective equipment for cleaning staff.

This includes:
 Single use latex gloves;
 Single use disposable plastic aprons;
 A supply of medicated wipes.

6) Removal of Waste

After cleaning each affected area or room, all waste including the protective
equipment should be removed, placed in a secure plastic bag and removed
carefully to a designated storage area. Thorough hand washing with soap and
hot water should then be carried out. Clean latex gloves and plastic aprons
should be used for each affected area to be cleaned.

How do I clean up after an incidence of sickness and diarrhoea?

Immediate action must be taken to clean up any sickness or diarrhoea.

Cleaning and disinfection can be divided into the cleaning of hard surfaces,
soft furnishings, rooms occupied by ill guests, public areas and swimming
pools.

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1) Hard surfaces

For hard surfaces carry out the following steps:

a. Clean Away Gross Contamination

Paper towels should be used to cover any gross contamination of vomit or

faecal material. Bleach should be soaked into the towels and then this
should be removed to a plastic bag that is securely sealed, either by tying
or using wire tags.

b. Wash with Hot Water and Detergent

When all gross contamination has been securely bagged then affected
surfaces must be cleaned with hot water and detergent.

c. Disinfect with Hypochlorite Solution

 Disinfect with a freshly prepared 0.1% hypochlorite bleach solution

(1000ppm). A domestic bleach solution at a dilution of 1:10 or a
Milton Fluid solution of 1:10 should satisfy the above requirement. It
is important to check the label for concentrations.
 For areas of gross contamination use a freshly prepared 1%
hypochlorite solution (10,000ppm) to disinfect.
 NEVER MIX CHEMICALS as this can affect the efficiency of the
chemicals and/or become hazardous to the users.

d. Cleaning of Fixtures and Fittings

Ensure thorough cleaning of all fixtures and fittings takes place e.g. the
bath, basin, toilet, the floor, walls, toilet paper holders, towel rails, flush
handles, light switches, and shelving. The same cleaning routine must be
undertaken in any affected bedroom or other area. Clean an area of at
least 3 metres in all directions from the vomiting incident.

e. Cleaning Techniques

 Use separate cleaning cloths and disposable paper towels for each
area e.g. one for a bathroom and another for the bedroom.
 Ensure you clean the toilet bowl last to prevent the risk of spreading
contamination.

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  Used bathroom towels must not be used to dry off wet surfaces as
this may only re-contaminate areas that have been effectively
disinfected.
 Toilet brushes and holders should be cleaned in a separate
container or bucket with a bleach solution.
 Cleaned and disinfected surfaces should be dried with disposable
paper towels. Leave windows open to allow air-drying.

f. Contamination in Bedrooms

Any used bleach solution should be flushed away after each room has
been cleaned to minimise the potential for cross contamination. Where a
contamination incident has occurred, all tea making provisions, cups,
glasses, teapots or other crockery should be sprayed with a hypochlorite-
based disinfectant spray, bagged and removed. It should be washed
separately from other hotel crockery.

g. Cleaners’ Equipment

Ensure all cleaners’ equipment is thoroughly disinfected in the same way

after use in each room.

Please note:
*Viral particles can survive up to 12 days on soft furnishings.
*An aerosol of viral particles can reach 3 metres from an incident of
vomiting (and possibly as far as 7-8 metres).

2) Soft furnishings

a. Avoid Use of Bleach Solution

The use of bleach solution to disinfect soft furnishings should be avoided

as this may damage these materials.

b. Removal of Contaminated Items

Any removable soft furnishings e.g. towels, bedspreads, cushions,

curtains, and tablecloths should be changed. Place contaminated items in
plastic bags for removal to the laundry. It is strongly recommended that
you use soluble alginate laundry bags that can be placed directly into the
washing machine thereby avoiding the risk of further exposure of the virus.

17
 These materials can be adequately washed on a hot wash cycle. This
must be as per instructions under 3)d.

c. Outside Laundry Service

If an outside laundry service is used then they should be advised of the

outbreak in order that their cleaning routines do not put themselves at risk.

d. Steam Cleaning

Carpeting and fixed seating should be cleaned, after removal of the gross
contamination, using a professional steam cleaner that includes a hot
water and detergent extraction system. Check that they are heat tolerant
before starting.

Domestic type or standard steam cleaners will not normally be effective

against viruses. The more extensive the area of cleaning the lower risk of
the virus surviving in the environment, however a minimum of at least 3
metres in all directions from the vomiting incident is recommended.

Do not dry vacuum carpets or other affected soft furnishings - this will
only spread the virus further by making it airborne.

3) Rooms occupied by ill guests

a. Clean and disinfect contaminated areas/objects as per Cleaning and

Disinfection Procedures.
b. Rooms should be thoroughly cleaned when the guests depart. These
rooms should be cleaned before other rooms so that they remain empty
of guests for the longest possible time.
c. Remove bedding and towels for laundering.
d. When handling used, soiled, fouled or infected linen, a disposable apron
and gloves should be worn. Laundry should be placed immediately in a
red water soluble (alginate) bag tied securely and placed in a linen bag
identified as infected linen for transfer to the laundry. The outer bag for
infected linen should be washed at the same time as the contents. Linen
should be laundered at a temperature of 71˚C maintained for not less
than 3 minutes or 65˚C maintained for not less than 10 minutes. Clothing
should be washed at the highest temperature recommended by the
manufacturer. After handling used, soiled, fouled or infected linen
remove gloves then apron and washed hands thoroughly..

18
e. Mattresses with wipe clean plastic covers, which have not been
contaminated, should be treated with a disinfectant or viricidal agent and
then aired in bright sunlight for a few hours if possible.
f. If possible duvets and pillows should be removed for cleaning. Where
this is not practicable they should be treated with a viricidal agent.
g. All hard surfaces and hand contact surfaces should be cleaned then
wiped down with a 0.1% Hypochlorite solution e.g. wash hand basins,
work surfaces, washable floors, taps, toilet and bath rails, telephones
and banisters, furniture, waste bins, door and toilet flush handles,
window frames and bathroom fittings. (This solution will bleach fabrics so
should not be used on soft furnishings or carpets).
h. Ensure separate disposable cloths are used for ‘dirty’ areas such as
toilets.
i. All tea making facilities and provisions, cups, glasses, teapots and other
crockery should be initially sprayed with a disinfectant or viricidal spray
and bagged. Thereafter the bag is sprayed over the exterior with the
viricidal spray prior to removal for cleaning and disinfection. This
procedure should also be followed when removing crockery etc after the
guest has had room service. All items should be washed separately from
other hotel crockery etc.
j. After room service the guest should collect the crockery, cutlery,
glassware etc and pass them through the doorway. Staff should not
enter the room.
k. Dispose of teabags, coffee sachets, biscuits and other consumables.
l. Replenish drinking water supplies where needed.
m. Dispose of all toilet rolls and other toiletries.
n. Hand towels should be changed at least daily in rooms where affected
persons are staying, although the use of disposable paper towels is
recommended.
o. Where possible ventilate the room.
p. If possible, affected rooms should be left unoccupied for 72 hours after
cleaning.

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What about fogging?

Fogging involves the atomising of stabilised chlorine dioxide using a fogging

machine. This should be undertaken by suitably trained personnel in order to
ensure that the dosage and application is correct. The time necessary for
effective treatment is unclear but may run to several hours.

Evidence to support the use of fogging is still largely anecdotal, however it

would appear that fogging may be of value if susceptible organisms are
suspended in the air and for the disinfecting of clean horizontal surfaces. It is
NOT to be regarded as a substitute for good, thorough cleaning. Fogging
must be carried out when rooms are unoccupied and all wardrobes, drawers,
chests etc are open during the process. Adequate ventilation of rooms after
fogging is essential.

4) Public areas

a. When sickness occurs in public areas e.g. public toilets, reception, dining
rooms, corridors etc. they must be cordoned off prior to cleaning being
undertaken. Some form of hazard warning tape is recommended to
prevent access to guests, residents or other members of staff.
b. Remember viral particles can travel a long way, so don’t confine the
cordoned off area to just the immediate area of contamination. Where
possible the areas to be cleaned and cordoned off should extend to at
least 3 metres around the area of vomit.
c. Advise staff on the methods to prevent other persons gaining access into
these areas until the cleaning staff can ensure the area is properly
cleaned.
d. Signs stating that toilets are out of use may need to be used during the
cleaning process and for a period afterwards to allow for surfaces to dry.
e. During an outbreak routine cleaning of public toilets, staff toilets and
shared bathrooms will need to be increased in frequency to at least four
times per day, preferably hourly, and after any incidence of soiling or
contamination. This may need to increase if there is evidence that the
outbreak is not under control.
f. Designate a member of staff to undertake a regular tour of all public
areas as this may identify areas needing urgent cleaning. Do not wait for
a member of the public to notify staff of an incident of sickness.
g. Ensure that paper towels are available in public toilet areas and foot
operated pedal bins for disposal in preference to hand dryers

20
 h. Turn off ceiling fans in public areas (this can also assist in the dispersal
of viral particles in large spaces)
i. Consider closing areas to non residents (e.g. bar and swimming pool
areas are sometimes open for use by non hotel guests)
j. Cover cutlery and crockery (pre use) in dining areas and consider
including alcohol hand gels at dining room entrances
k. Remove communal newspapers and magazines from public areas.

5) Swimming pools

If a vomiting or diarrhoea incident occurs in or close to the pool:

a. Clear the pool of bathers immediately.

b. Ensure that disinfectant levels are maintained at the top of the range.
c. Use a coagulant and filter the water for six turnover cycles.
d. Backwash the filter throughout this operation.
e. Subject to clarity of water and satisfactory pH and chlorine levels the
pool can then be re-opened.
f. Records should be maintained of the incident and all subsequent actions
taken.
g. Instructions for cleaning and disinfection (i.e. instructions as detailed in
Cleaning and Disinfection Procedures) should be followed for pool
surrounds and communal areas.
h. The areas to be cleaned and cordoned off should extend to at least 3
metres around the area of gross contamination.

21
Precautions to take for guests on departure/ before
arrival

In order to prevent the spread of infection from a departing group to another

arriving at the premises you should ensure that:

 Departing guests are separated from arriving guests either by using

separate entrances or by time.
 Ill guests should not be put on transfer coaches but rather sent home
independently.

Procedures for coach travel

Many hotels will deal with the arrival of coach parties on a regular basis. This
includes the initial journey to a hotel, local coach trips within a resort area and
the return journey home. Incidents of sickness can affect any of these trips.

A procedure should be set up to deal with incidences of sickness that may be

attributed to Norovirus. In order to reduce the risks of infection to others the
following guidelines should be followed:

1) Where a passenger is sick on a journey then the coach should park and
allow all passengers to disembark, prior to any cleaning operation. This will
help reduce the risk of further infection.

2) The coach tour operator should have an ‘Action Pack’ on board. This can
include a supply of the following:

 Adequate supply of water (preferably hot) for cleaning

 Pre-diluted bleach of a 0.1% Hypochlorite solution
 Single-use latex gloves
 Disposable aprons
 Disposable foot covers
 Dustbin bags in a distinctive colour
 Metal/ plastic tags to close the bags
 Sick bags
 Hypochlorite-based disinfectant
 Detergent

22
  Absorbent granules
 Disposable cloths
 Mop, bucket, dustpan and plastic scraper
 Disposable paper towels

The Action Pack should be stored in a designated place on the coach. The
hotel/ tour operator should ensure that adequate supplies of these materials
are on board and should assist in providing further materials as required.

3) Designate a separate area for the storage of contaminated waste away

from personal belongings and foodstuffs. These materials should be handed
over at the end of the journey or tour to either the coach tour operator or the
hotel management for its safe disposal.

4) The same cleaning procedures should be followed as stated in “Cleaning

and Disinfection Procedures”.

5) If sickness occurs in the toilet compartment it should be locked or taken out

of use until thorough cleaning and disinfection can take place at the end of the
journey. All contaminated waste within the storage tanks on board must be
carefully disposed of to the drainage system upon return from the journey.

6) Isolate the air conditioning system and do not reintroduce until the coach
has been cleaned.

7) At the early stages of an outbreak local tours may need to be cancelled to

prevent the risk of further spread of infection. It is vital to prevent cross
infection with parties from other hotels.

Arrival at base/destination

The coach tour operator will need to have a procedure for cleaning and
quarantining an affected coach at the earliest opportunity either upon the
completion of a return journey to a home area or during a stay. This will
include:

23
  The steam cleaning of seats and other soft furnishings.
 Thorough cleaning and disinfection of hard surfaces.
 The removal of headrest covers, cushions etc. for laundering above
60ºC.
 Removal and proper disposal of consumables e.g. paper cups.
 Where fogging is to take place, cleaning should be carried out first and
then the disinfectant allowed to permeate the vehicle, including the air
conditioning system, which should be switched on to recirculate.

A period of 72 hours is recommended between the cleaning/disinfecting of a

coach and it being brought back into use.

Advanced warnings and information should be given to drivers and coach tour
operators to ensure the most appropriate course of action is undertaken.

24
Appendix 1: Flow chart showing action plan for premises
before an outbreak of viral gastroenteritis occurs

Premises to form
an outbreak control group
Including key individuals, e.g. General
Manager, Heads of Department, Cleaning
Supervisor

Develop an Purchase a
action plan supply of
necessary
cleaning
equipment and
cleaning
chemicals.
Provide information and
instruction to all
Staff re: action plan and reporting
of sickness incidents
E.g. including stewards,
housekeeping staff, food handlers,
coach drivers, night staff, reception,
porters

Periodically
check supplies
of cleaning
Train relevant chemicals to
Form a
staff in cleaning ensure they are
cleaning
methods properly stored
‘hit squad’ and within
E.g. dilutions,
use of date.
equipment

25
Appendix 2 – Contacts list for Environmental Health Officers
in North Yorkshire and York
Craven District Council:
Environmental Health Unit, 1 Belle Vue Square, Broughton Road, Skipton,
BD23 1FJ. Tel no: 01756 706347

Hambleton District Council

Civic Centre, Stone Cross, Northallerton, BL6 2UU
Tel no: 01609 779977

Harrogate Borough Council

Safer Communities, P0 Box 787, Harrogate, HG1 9RW
Tel no: 01423 500600

Richmondshire District Council

Mercury House, Station Road, Richmond, North Yorkshire, DL10 4JX
Tel no: 01748 829100

Ryedale District Council

Environment, Ryedale House, Old Malton Road, Malton, YO17 7ZG
Tel no: 01653 600666

Scarborough Borough Council

Town Hall, Scarborough, YO11 2HG
Tel no: 01723 232323

Selby District Council

Environmental Health, Doncaster Road, Selby, YO8 9FT
Tel no: 01757 705101

City of York Council

Public Protection, Hazel Court, James Street, York, YO10 3DS
Tel no: 01904 551525

26
Appendix 3: Flow chart showing action plan where an
outbreak of gastroenteritis occurs

Hotel inform environmental health about outbreak

EHO PHE Y&H

investigation investigation

Ensure premises has

guidance document.
Investigation
Arrange of food Provide initial infection
collection of hygiene and control guidance; premises
faecal kitchen to implement:
specimens  Enhanced cleaning
and  To inform all staff and
submission to strict exclusion of ill
laboratory as staff
quickly as  To inform all guests of
practicable outbreak
 To collect information
on all cases of illness
Premises to report (staff and guests)
numbers of illness to
PHE Y&H daily

review
cases

cases

Monitor
cases of
illness for 1
Premises to PHE Y&H to week
inform inform
booked CCG/GPs/
groups due Trusts as
to arrive appropriate
PHE Y&H/EHO
to agree when
outbreak
declared over

27
Appendix 4: Collection of faecal specimens

EHO to leave postal specimen pots and

packaging x 6 at premises

 Specimen pot
 Instructions for collection
 Laboratory forms with details
completed for sample, test
requested, clinical details, I-
log
 Postal packaging

Premises give to guests /

staff only when identified
as currently having
diarrhoea or vomiting*

Patient liaises with EHO EHO arranges to

and where agreed, follows collect from
instructions and completes patient/hotel staff
the details on the form

Local hospital
POST Laboratory
 Must be correctly
packaged
 contain correct
Leeds General
postage Infirmary
Laboratory

Results

EHO GP
HPU

PHE Patient
Y&H
*the test is unlikely to give an accurate answer if the symptoms have ceased even
though someone might still feel generally tired and unwell following illness. Testing
should only be given to those who have symptoms of diarrhoea or vomiting on that
day. The testing is done for public health purposes to identify the outbreak, it is not
necessary to confirm Norovirus in all individuals once this has been established.

28
Appendix 5: Faecal specimen request form – example and
blank copy

Forename James Date of Birth 05/10/64

Surname Brown Telephone/mobile 07812 345678

number
Address 5 Park Road, GP name, Dr Smith and
Kingston address Partners,
and postcode
(if known) Carlisle Street
Practice,
Post code KT5 4JA Kingston, KT5
3LP
Temporary Palm Springs
address It is very important to put on all these
Hotel, York details otherwise the specimen may
(e.g. hotel) and
postcode not be processed by the laboratory

Specimen type Faeces

(e.g. faeces)
Date of 08/08/2011 Time of 3.45pm
specimen specimen
Tests required Microscopy, culture and sensitivities plus virology

Clinical details ?Norovirus infection This must be written clearly otherwise

the laboratory may not test the
specimen

Requesting Public Health England Yorkshire and the Humber

Authority
I log number YH56789
This can be provided by
the EHO or PHE Y&H
Please send a copy of the result to the PHE Yorkshire and the Humber,
Block 2, National Agri-food Innovation Campus, Sand Hutton, York,
YO41 1JD tel. no: 01904 687100

29
Faecal specimen request form

Forename Date of Birth

Surname Telephone/mobile
number
Address GP name,
address
and postcode
(if known)

Post code

Temporary
address
(e.g. hotel) and
postcode

Specimen type
(e.g. faeces)
Date of Time of
specimen specimen
Tests required

Clinical details

Requesting
Authority
I log number

Please send a copy of the result to the PHE Yorkshire and the Humber,
Block 2, National Agri-Food Innovation Centre, Sand Hutton, York, YO41
1LZ tel. no: 01904 687100

30
Appendix 6: Specific note on oysters

Handling and serving live oysters in your hotel or restaurant is different to

other ready to eat foods. You need to look after a live animal and ensure that
it remains alive until it is either eaten or cooked. Where oysters are eaten raw
the main health controls will have occurred at the place of depuration and
dispatch. In the event of an incident or recall it is essential to be able to trace
oysters back to the dispatch centre they came from. Records kept there will
be able to trace the oysters further back to the actual harvesting bed they
came from. This will allow individual beds to be closed if necessary to protect
the health of consumers. These notes will help you to maintain traceability
and maintain your oysters in the best condition so that the health and
satisfaction of your customers is safeguarded.

Traceability

All packages of live oysters must be accompanied by a health mark on an

indelible, water resistant label. This shows the identification number of the
establishment from which they have come and a batch number. These two
details should be sufficient to identify the actual bed from which the oysters
were harvested. By law the retailer or caterer must keep the health mark for at
least 60 days in case this information is needed. The easiest way to do this is
to staple the label into a large diary at the day of delivery (Do this in a non-
food area to avoid contaminating food with staples). If any of your customers
inform you that they have been ill as a result of eating oysters at your
premises, contact the Environmental Health Officer at once and give them the
details from the relevant label.

Try to avoid using oysters from different suppliers at the same time but, if this
is unavoidable, devise your own method of being able to identify who ate
oysters from which supplier. The health mark also states “These animals must
be alive when sold”. You have to make sure they are alive when sold or
cooked. If they are not tightly closed or do not rapidly close tightly when
tapped – they are dead and should not be used.

Reception and Handling of Oysters

Reception

 Check the health mark. If there is no heath mark reject the

consignment.

31
  Check that the vehicle is clean and that the oysters have not been
mixed with raw fish or kept in hot and dirty conditions.

Storage

 Always keep the oysters stored with the curved (convex) side
downwards. This helps to retain the fluid in the shell and keep them
alive.
 Store the oysters in a deep bowl (to prevent leaks) and away from
other open foods.
 Keep them cool (4°C – 8°C is good). Remember, these are live animals
so you don’t want to freeze them.
 Do NOT re-immerse oysters in water. They will have been properly
purified at the depuration centre and any further immersion risks
recontaminating them.
 If stored as shown above the oysters should last at least 5 days.

Handling

 Wash your hands thoroughly before opening the oysters.

 Ensure that the knives and other equipment (including gloves if you
wear them) used for opening the oysters and the area you are working
in are all clean before you start.
 Check that the outside shells of the oysters are clean and avoid
pushing any mud or bits of shell into the oyster as you open it.
 Use a cleaned or different shucking knife for each batch
 Serve promptly

Information on oysters and other shellfish can be found on the internet at:
https://www.food.gov.uk/business-industry/fish-shellfish

32
Appendix 7: Information for hotel guests

Illness precautions

You may be aware that this hotel is currently implementing special

arrangements following reports that some of our guests have become unwell
recently. Be assured that the premises has a comprehensive action plan in
place, aimed at minimising the spread of illness to fellow guests.

If you are unfortunate enough to become unwell with symptoms of sickness

and/or diarrhoea, please notify the management as soon as possible. You
may be required to submit a sample for analysis.

What should you do now?

 Regular hand washing will reduce the likelihood of contracting the

illness.
 Use the toilet facilities in your own room rather than those in public
areas.
 Report any spillages or vomiting to reception.

Special health precautions

If your GP has previously advised that you must avoid environments that may
risk compromising your immunity, please notify the hotel management, who
will attempt to make alternative arrangements for you.

If you become unwell during your stay

 Notify hotel management as soon as possible

 Stay in your room and do not attend public gatherings until at least 48
hours from your last episode diarrhoea or vomiting. Try to be
considerate to fellow customers. Often symptoms will last for only a day
or two.
 Discourage any friends or family from visiting you even though they
may wish to.
 Do not share food from open packets with anyone else (e.g. biscuits)
 Hotel staff will attempt to make you as comfortable as possible during
any period of illness.

33
Appendix 8: General information for the public

Norovirus, which causes diarrhoea and vomiting, is one of the most common
stomach bugs in the UK. It's also called the "winter vomiting bug" because it's
more common in winter, although you can catch it at any time of the year.
Norovirus can be very unpleasant but it usually clears up by itself in a few
days. You can normally look after yourself or your child at home.

Try to avoid going to your GP, as Norovirus can spread to others very easily.
Call your GP or NHS 111 if you're concerned or need any advice.

Symptoms of Norovirus

You're likely to have Norovirus if you experience:

 suddenly feeling sick
 projectile vomiting
 watery diarrhoea

Some people also have a slight fever, headaches, painful stomach cramps
and aching limbs. The symptoms appear one to two days after you become
infected and typically last for up to two or three days.

What to do if you have Norovirus

If you experience sudden diarrhoea and vomiting, the best thing to do is to

stay at home until you're feeling better. There's no treatment for Norovirus, so
you have to let it run its course. You don't usually need to get medical advice
unless there's a risk of a more serious problem.

34
To help ease your own or your child’s symptoms:
 Drink plenty of fluids to avoid dehydration. You need to drink
more than usual to replace the fluids lost from vomiting and
diarrhoea – as well as water, adults could also try fruit juice and soup.
Avoid giving fizzy drinks or fruit juice to children as it can make their
diarrhoea worse. Babies should continue to feed as usual, either with
breast milk or other milk feeds.
 Take paracetamol for any fever or aches and pains.
 Get plenty of rest.
 If you feel like eating, eat plain foods, such as soup, rice, pasta and
bread.
 Use special rehydration drinks made from sachets bought from
pharmacies if you have signs of dehydration, such as a dry mouth or
dark urine.
 Adults can take antidiarrhoeal and/or anti-emetic (anti-vomiting)
medication – these are not suitable for everyone though, so you
should check the medicine leaflet or ask or your pharmacist or GP for
advice before trying them.

Babies and young children, especially if they're less than a year old, have a
greater risk of becoming dehydrated.

Norovirus can spread very easily, so you should wash your hands regularly
while you're ill and stay off work or school until at least 48 hours after the
symptoms have cleared, to reduce the risk of passing it on.

When to get medical advice

You don't normally need to see your GP if you think you or your child has
Norovirus, as there's no specific treatment for it. Antibiotics won't help
because it's caused by a virus.

Visiting your GP surgery with Norovirus can put others at risk, so it's best to
call your GP or NHS 111 if you're concerned or feel you need advice.

Get medical advice if:

 your baby or child has passed six or more watery stools in the past 24
hours, or has vomited three times or more in the past 24 hours

35
  your baby or child is less responsive, feverish, or has pale or mottled
skin
 you or your child has symptoms of severe dehydration, such as
persistent dizziness, only passing small amounts of urine or no urine at
all, or reduced consciousness – babies and elderly people have a
greater risk of becoming dehydrated
 you have bloody diarrhoea
 your symptoms haven't started to improve after a few days
 you or your child have a serious underlying condition, such as kidney
disease, and have diarrhoea and vomiting

Your GP may suggest sending off a sample of your stool to a laboratory to

confirm whether you have Norovirus or another infection.

How is Norovirus spread?

Norovirus spreads very easily in public places such as hospitals, nursing

homes and schools.

You can catch it if small particles of vomit or poo from an infected person get
into your mouth, such as through:

 close contact with someone with Norovirus – they may breathe out
small particles containing the virus that you could inhale
 touching contaminated surfaces or objects – the virus can survive
outside the body for several days
 eating contaminated food – this can happen if an infected person
doesn't wash their hands before handling food

A person with Norovirus is most infectious from when their symptoms start
until 48 hours after all their symptoms have passed, although they may also
be infectious for a short time before and after this.

You can get Norovirus more than once because the virus is always changing,
so your body is unable to build up long-term resistance to it.

36
Preventing Norovirus

It's not always possible to avoid getting Norovirus, but following the advice
below can help stop the virus spreading.

 Stay off work or school until at least 48 hours after the symptoms
have passed. You should also avoid visiting anyone in hospital during
this time.
 Wash your hands frequently and thoroughly with soap and water,
particularly after using the toilet and before preparing food. Don't rely
on alcohol hand gels, as they do not kill the virus.
 Disinfect any surfaces or objects that could be contaminated. It's
best to use a bleach-based household cleaner.
 Wash any items of clothing or bedding that could have become
contaminated separately on a hot wash to ensure the virus is killed.
 Don't share towels and flannels.
 Flush away any infected poo or vomit in the toilet and clean the
surrounding area.
 Avoid eating raw, unwashed produce and only eat oysters from a
reliable source, as oysters can carry Norovirus.
Taken from nhs.uk/conditions/Norovirus/Pages/Introduction.aspx July
2017

37
Handwashing technique

Taken from: http://www.who.int/gpsc/clean_hands_protection/en/, July 2017

Appendix 9: Illness report form (for hotel guests)
***PLEASE COMPLETE ONE FORM PER ILL PERSON*****
Your details
Name

Date of birth
Home address

Post code Phone

number
GP name and address
GP contact telephone
number (if known)

Room number Date Date departed/ due

arrived to leave
Details of party
travelling with (if
applicable)

Symptoms (please tick)

Diarrhoea Vomiting
Abdominal pain Nausea
Bloody diarrhoea Loss of appetite
headache tiredness
fever Other
If other, please specify

Onset (first episode of either Date Time Am/pm

diarrhoea or vomiting) (approx)
Last episode of diarrhoea or Date Time Am/pm
vomiting (approx)

Stool specimen details

Sample taken Date
Laboratory/ hospital submitted to

Details of food or drink in last 48 hours (where eaten and what food?)
On day of illness

Day before illness

Two days before illness

39
Illness report form (for restaurant guests only)
***PLEASE COMPLETE ONE FORM PER ILL PERSON*****
Your details
Name

Date of birth
Home address

Post code Phone

number
GP name and address
GP contact telephone
number (if known)

Date eaten
Details of food eaten

Symptoms (please tick)

Diarrhoea Vomiting
Abdominal pain Nausea
Bloody diarrhoea Loss of appetite
headache tiredness
fever Other
If other, please specify

Onset (first episode of either Date Time Am/pm

diarrhoea or vomiting) (approx)
Last episode of diarrhoea or Date Time Am/pm
vomiting (approx)

Stool specimen details

Sample taken Date
Laboratory/ hospital submitted to

40
Illness report form (for staff)
***PLEASE COMPLETE ONE FORM PER ILL PERSON*****
Your details
Name

Date of birth
Home address

Post code Phone

number
GP name and address
GP contact telephone
number (if known)

Job title
Did you develop any symptoms of diarrhoea or vomiting while at work? Yes/no
Did you report this immediately to your line manager? Yes/no
Did you leave work immediately? Yes/no
When did you return to work? Date Time Am/pm
(approx)

Symptoms (please tick)

Diarrhoea Vomiting
Abdominal pain Nausea
Bloody diarrhoea Loss of appetite
headache tiredness
fever Other
If other, please specify

Onset (first episode of either Date Time Am/pm

diarrhoea or vomiting) (approx)
Last episode of diarrhoea or Date Time Am/pm
vomiting (approx)

Stool specimen details

Sample taken Date
Laboratory/ hospital submitted to

41
Appendix 10: outbreak summary sheet (for hotel guests)
Name Room Date Date departed/ Date of onset (first Date of last Stool sample
number arrived due to leave episode of episode of submitted
diarrhoea or vomit) diarrhoea or vomit (yes/no)

42
Outbreak summary sheet (for restaurant guests only)
Name Date eaten Symptoms of Symptoms of Date of onset Date of last Stool
vomiting diarrhoea (first episode of episode of sample
present present diarrhoea or diarrhoea or submitted
(yes/no) (yes/no) vomit) vomit (yes/no)

43